insurance, transportation barriers, and problems with clinician attitudes and competence in caring for people with disabilities.
Some studies of the use of health care services by people with disabilities hint at possible physical access effects. For example, an analysis based on the Medicare Current Beneficiary Survey found that disability, especially severe disability, was a significant risk factor for not receiving mammograms and Pap smears but not influenza and pneumococcal vaccinations, which do not require major equipment or equipment modifications (Chan et al., 1999). An analysis of data from the California Health Interview Survey reported that people with a probable disability were statistically significantly less likely than others to have received screenings for breast, cervical, or prostate cancer; the differences for colon cancer screening were not statistically significant (Ramirez et al., 2005). People with a probable disability were, however, more likely than others to report a usual source of care and health insurance coverage, characteristics that usually predict increased use of preventive services. Another study that used data from the Behavioral Risk Factor Surveillance System in 2000 reported that “people with mild and moderate disability received influenza and pneumonia vaccinations somewhat more frequently than people without disabilities, but people with the most severe disabilities least frequently received vaccinations” (Diab and Johnston, 2004, p. 749). A recent review of studies of screening for breast and cervical cancer and osteoporosis concluded that women with more severe disabilities were less likely to be screened than women with mild or moderate disabilities (Smeltzer, 2006). An earlier study with data from the National Study of Women with Physical Disabilities found similar results for pelvic examinations but no differences for mammograms for women with or without disabilities (Nosek and Howland, 1997). Again, these various survey findings could reflect a number of factors other than or in addition to the physical accessibility of facilities and equipment.
The federal government has taken a number of steps over several decades to make public spaces and buildings more accessible to people with disabilities, first in federal facilities and then in many private facilities that are used by the public. (State policies are not reviewed here.) These policies have had positive effects, although as described below, changes in both the content and the implementation of federal policies would allow more progress.
In 1968, the Architectural Barriers Act (ABA) established requirements for accessibility in buildings designed, built, altered, or leased with federal funds. As discussed in more detail below, the Rehabilitation Act of 1973